Latest Inspection
This is the latest available inspection report for this service, carried out on 11th July 2008. CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for Charnwood Hall Nursing Home.
What the care home does well The care needs of clients are well met. What has improved since the last inspection? A new sun lounge and conservatory has been provided creating extra space for people living at the care home to meet visitors, friends or relatives. The dining room has been extended to create more dining space for people living at the home. New living room chairs and furniture for the conservatory have been purchased to make the home more comfortable for the people who live there and for those visiting. What the care home could do better: Recruitment practices should be improved. An update of the information relating to the contact details for the Commission for Social Care Inspection (CSCI) is to be changed to reflect the Regional office, Cambridge address. CARE HOMES FOR OLDER PEOPLE
Charnwood Hall Nursing Home 38 Charnwood Road Shepshed Loughborough Leicestershire LE12 9QF Lead Inspector
Lesley Allison-White Unannounced Inspection 11th July 2008 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Charnwood Hall Nursing Home Address 38 Charnwood Road Shepshed Loughborough Leicestershire LE12 9QF 01509 650717 01509 506300 stinchcombe@madasafish.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Quality Care Midlands Ltd Mrs Lynne Stinchcombe Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age of places (25) Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Charnwood Hall Nursing Home is registered to provide personal care to male and female service users who fall within the following categories: Old age, not falling within any other category (OP) 25 2. 3. Physical disability over 65 years of age PD(E) 25 To accommodate at Charnwood Hall Nursing Home the person named in variation number V33780 who falls within the category of LD (E) The maximum number of persons to be accommodated at Charnwood Hall Nursing Home is 25 20th July 2006 Date of last inspection Brief Description of the Service: Charnwood Hall Nursing Home is a care home situated centrally in Shepshed Leicestershire. The home is owned by a Limited Company called Quality Care Midlands Limited. It is registered to accommodate twenty-five people with physical disabilities and old age. It is situated on a main road within a five-minute walk of the town centre. It is also on a public transport route. Facilities close by include several churches, and a number of social amenities including restaurants, a bowling green, local market and a number of public houses. The local community centre is within walking distance of the home. The registered provider employs registered nurses, care and ancillary staff (a number of whom have been employed for many years). The town has two main General Practitioner (GP) practises which people living at the home are registered with. Charnwood Hall was originally a Manor House, which was developed and modernised by the present owners. It is traditional in design and is furnished and fitted to a good standard and offers people living there comfortable, homely surroundings. It has a main lounge. A separate dining room is located next to the lounge, this has been extended. The home has two floors with a passenger lift between each floor. The home has fifteen single bedrooms and three double of which seven are en-suite. A conservatory has been built. The home has a small area for parking cars. Fees range from £400.00 to £500.00 per week.
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 5 The Statement of Purpose and Service User Guide (information about the service provided) is available. The Commission for Social Care Inspection (CSCI) and the Employers Liability certificate is displayed in the foyer of the home. A copy of the Commission of Social Care Inspection report is available on request from the office. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate, quality outcomes.
The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for the people who use the service and their views of the service provided. The home provides care for up to twenty-five people. On the day of inspection there were twenty people living at Charnwood Hall Nursing Home. The inspection took six and a half hours to complete. Preparation included examining inspection records and information obtained from the CSCI preinspection questionnaire from the Provider about Charnwood Hall Nursing Home. This aided the inspection process by providing background information. Discussion was held with six people living at the care home. Other people were observed in their daily routine. One of the people who the inspector saw was unable to communicate verbally but was able to nod their answers. Five relatives also spoke with the inspector at length. The primary method of inspection used was “case tracking”. This involved speaking with the people who use the service provided, looking at three people’s care plans and making observations. (Care plans are notes about the care provided for each individual). All the required key standards were inspected during this visit. One requirement and two recommendations were made at this inspection. The Registered Nurse on duty facilitated the inspection. What the service does well:
The care needs of clients are well met. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is good and the pre-admission process ensures that the needs of the people living at this home will be met. EVIDENCE: The relatives who spoke with the inspector said they had been provided with a Service User Guide and Statement of Purpose about the services the home offers. This service has links with a local advocacy services and the advocacy service helps people to complete questionnaires about life at the home independent of staff help and are available to anyone who needs their help. Contracts with Social Services were also seen in two of the care records inspected. Three peoples care records were looked at in detail. There was evidence of assessments undertaken by the Registered Manager that covered their social and medical needs. A trial period of up to one month forms part of the assessment process when deciding if this home is right for the prospective
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 10 person. Pets are welcomed at the home unless there are health and safety reasons that would affect the decision. Currently two budgerigar’s and fish live at the home. A recommendation will be made for information relating to the contact details for the Commission for Social Care Inspection (CSCI) to be changed to reflect the Regional office, Cambridge address. The home does not offer intermediate care facilities. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At Charnwood Hall Nursing Home staff are successful in delivering appropriate care to individuals. People living there have their care needs met. EVIDENCE: The Registered Manager carries out audits on equipment used in the home, a quality assurance audit and medications. Many staff at the home has recently completed the Liverpool pathways course about care of the dying person. Certificates for the staff that have successfully completed the course are to be sent by the course providers. In the care records of the three people case tracked assessments for care and social needs were evident and evaluation of the care given had also taken place. Involvement of specialist support such as the dietician, or chiropodist visits were also evident. The General Practitioner (GP) visits Charnwood Hall Nursing Home each week. The Registered Nurse also said that the GP would visit happily visit in between when needed. The Registered Nurse said that the relationship with the local medical, nursing and support services was very
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 12 good and that people living at the home were not kept waiting for extra care support. Comments from some of the people who live at Charnwood Hall Nursing Home included ‘I feel that I get good help here, they (the staff) look after me’. ‘The call bell is usually left where I can use it and the staff are very helpful’. ‘The staff are nice and very helpful almost as good as being in your own home’. ‘When I was poorly I was well looked after here. The staff visited me regularly to make sure that I was fine’. Relatives’ comments included ‘My parent is well fed and their weight is stable. My parent likes to have a lie in, in the mornings. Staff helps them to do this’. ‘I like to be kept informed about my parent’s condition for any changes, GP visits and falls. The staff will contact me as requested.’ ‘We are involved in the care planning process as relatives and able to support our relative in this way. We also attend care planning reviews held with social services’. Staff was observed supporting and assisting people during different tasks, individuals were unrushed and treated with dignity. Medications of those case tracked were checked and fine. This included controlled drugs. These are medicines that the law states need special care and precautions when handing them. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities within the home succeed in meeting the identified daily and social needs of the people living at the home and the outcome is positive for them. EVIDENCE: Activites seen by the inspector appeared to suit the needs of the people living at the home. On the day of inspection in the morning four staff members were involved in the activities. Five to six people actively took part in a game of ‘eye spy’ this is a guessing game for seeing objects or remembering objects in the room then naming them. The staff made that game enjoyable and funny and worked together to include as many people as they could. In the evening two entertainers visited who sang familiar tunes and played music and those who were able to, clapped along with the tunes many people seemed to enjoy the music provided. Some people joined in the singing. Monthly entertainers are booked who visit the home. Sometimes entertainers are booked more frequently as shown on the activities sheet provided by the home. Religious services are held within the home for those wishing to take part. Individuals felt that their cultural and spritual needs were caterered for whilst living at Charnwood Hall Nursing Home.
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 14 One person said that they did not seem to be able to follow a television (TV) soap programme and that they may prefer to watch TV in their bed room as part of their one to one activity programme. One person said that they enjoyed doing jigsaw puzzles and would like to do some more of these as part of their activity programme. Two other individuals who spoke with the inspector said that they took part in board games and bingo and won prizes. Friends and families who spoke with the inspector said that they were made to feel welcome by the staff who worked at the care home and that ‘it was nice to see the same faces each week’. Visitors were seen visiting friends and relatives during the day and later in the evening. There are a number of quiet areas throughout the home where individuals can talk priviately if they wish to. An external hairdressing service visits to provide hairdressing services to anyone who requests this. Some people said that they went out in the local community, they said that their families helped them to achieve this. Many people said that their visitors were made to feel very welcome and that they felt they were still in contact with their local community. One relative said that their relative chooses to get up later in the mornings this is respected by staff that assist them to get up later. They explained that as a result of rising later their relative remains awake and enjoys their meals by staying awake and feeding themselves without assistance. Independence is maintained in this way. ‘When my relative has ‘little accidents’ this is dealt with quickly by the staff.’ ‘My parent is well fed and their weight is stable’. Individuals said that the food at the home was very good and that they liked the food provided for them to eat. A lunch time and tea time meal was seen taken in the dining room by the majority of people living at the home, those not able or wishing to dine in the dining room were taken meals on trays in their bed rooms. Some people spoke quietly at lunch time to each other. People who spoke with the inspector said that meal times was a pleasant experience. The inspector observed the staff seated and providing assistance to those who needed more assistance to enjoy their meal. Staff was seen putting on new plastic aprons on entering the dining room. A sink with hot and cold water is provided in the dining room a staff member was observed to use this prior to attending to any food. This is good practice. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are policies and procedures for dealing with complaints and protection thereby giving protection to the people living at Charnwood Hall Nursing Home. EVIDENCE: The Commission of Social Care Inspection has received two complaints about Charnwood Hall Nursing Home since the last inspection. They have been dealt with. People who spoke with the inspector explained what they would know what to do if they had a problem and knew that the Registered Manager would address them. There are policies in place for dealing with complaints and protection. The Registered Manager was not available on the day of inspection and some of the staff training records was not available. Staff records from the inspection are to be sent through as requested. Two staff members who were fairly new were not fully aware of the Protection of Vulnerable Adults (POVA) issues. However, they both understood the principles of ‘whistle blowing’. Both said that they would go to the person in charge of the shift. (Whistle blowing is a procedure used for reporting another
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 16 member of staff when an aspect of care is not being given in an appropriate manner and the individual receiving care or lack of it is affected in an adverse way). Another staff member with more experience who spoke with the inspector was able to demonstrate their understanding of the issues involved ensuring that people living at Charnwood Hall Nursing Home are protected in this way. The staff that spoke with the inspector all said that they had received an induction at the home. The complaints book was checked and satisfactory. The complaints procedure is included in the Service User Guide and Statement of Purpose and will need to be updated with information about the Commission for Social Care Inspections (CSCI) new address and contact details. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a safe, hygienic and comfortable environment. EVIDENCE: The inspector saw two bedrooms they were clean, uncluttered and tidy. One of the bedrooms had a specialised mattress in it and bed rails assessed to be the most appropriate way of protecting the person from fall injuries when in bed. Some bedrooms had toilet and face basin facilities in them. The corridors were well-lit, clean uncluttered areas. One bathroom was seen, it had a bath chair for people who needed assistance in this way. The bathroom was clean and tidy with doors that locked ensuring privacy when needed. Parts of the home have been redeveloped. There is a new sun lounge and the dining room has been extended and conservatory has been completed. People who spoke with the inspector said that they had been kept informed of the new developments.
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are well trained and supported. Staff receives supervision in this way the people living at this home are protected and not put at risk. EVIDENCE: Some of the staff records contained evidence of relevant training. This included Moving and Handling, National Vocational Qualification (NVQ) level 2 in care, First Aid, Fire and the Protection of Vulnerable Adults training. However, the two staff members’ case tracked will need to have their information sent through as requested. The Registered Nurse explained that the numbers and skill mix of staff were sufficient to meet the needs of the residents. On appearance this did seem to be so. Specialist training such as care of the dying has recently been undertaken. The Registered Manager does supervisions of staff at regular intervals. Information about recruitment, including CRB, POVA first checks, two staff references and training profiles of two staff members was not available at inspection. This information has now been provided and is incomplete.
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home have confidence in the safe working practices of the staff. In this way they remain protected. However, improvements must be made in the area of recruitment. EVIDENCE: A quality assurance assessment is carried out each year by the management team. An independent advocacy service is invited to help individuals complete their surveys. Some of the 2007 surveys were seen and were giving praise to the home. The 2008 surveys are to be done. Money and accounts belonging to those people case tracked were inspected and were found to be in order and well audited. People are encouraged to
Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 20 keep and manage small amounts of money for themselves and families are encouraged to manage their relative’s money as appropriate. The Registered Nurses and the Registered Manager who does formal supervisions with staff whilst working on the floor supervise staff in their daily work. Improvements in the paper work for recruitment practices must be improved. A requirement has been made for this to happen. A maintenance person is employed at the home; maintenance records and procedures are maintained. Accident records were seen they had good evidence of clear after care given following an accident. The inspector was informed that Health and Safety checks were up to date. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
3CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement The Registered Provider (owner) and the Registered Manager must ensure that all staff files contain all of the necessary information, as described in the Care Homes Regulations 2001, Regulation 19, Schedule 2 & Schedule 4.6, including references and proof of CRB checks which are available for inspection. Timescale for action 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations A recommendation will be made for information relating to the contact details for the Commission for Social Care Inspection (CSCI) to be changed to reflect the Regional office, Cambridge address. Charnwood Hall Nursing Home DS0000054117.V368248.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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